Prevention of Healthcare‐ Associated Legionella …€enteric gran negative rod bacteria (GNR) ......

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Helping People Live better Lives. 1

Prevention of Healthcare‐Associated Legionella Disease, and other HAIs

Sue Dempsey, MS

Maureen Tierney, MD, MSc

Alison Keyser‐Metobo, MPH

Nebraska Department of Health & Human Services

H elping People Live Better Lives.H elping People Live Better Lives.

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HAI program

Antibiotic stewardship and resistance

Outbreak detection and management

Waterborne causes of non‐GI illnesses

Legionella

Legionella water management programs

What is this talk about?


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DHHS Lincoln, DPH, EpidemiologyHAI Office @ DHHS Lincoln, DPH, EpidemiologyDHHS Environmental HealthICAPASAPMDStewardshipNPHLSafe Infection ProgramHAI Advisory Committee

Who are we?

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Dr. Maureen Tierney‐Director, Collaboration, Partnerships Dr. Caitlin Pedati‐Outbreak Detection and ManagementMargaret Drake, IP‐NHSN Data Validator and IP MentorPeg Gilbert, RN, CIC, Safe Injection Program

HAI Program Lincoln


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CDC funded via Ebola supplement to the ELC

Voluntary and Confidential

Evaluates Infection Control Practices and proposes mitigation

• Acute Care Hospitals, esp. CAH

• Long‐term Care

• Ambulatory Clinics

• Dialysis

ICAPInfection Control Assessment and Promotion Program


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Evaluates antimicrobial prescribing practices in selected acute care hospitals and long term care facilities

Provides expert support in creation of antibiograms, ID pharmacy consultation, techniques for stewardship

Utilizes data to create tools for all facilities to access on website (ASAP Nebraska)

This year assessing sustainability of programs put into placeAntibiotic Symposium, webinars and lectures

ASAPAntimicrobial Stewardship Assessment and Promotion Program

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Telemedicine Model for antibiotic stewardshipAssess stewardship program and capacity onsiteHelps set up formulary changes, antibiogramsDaily teleconference re‐casesGrant funding for 5 rural critical access hospitalsAS expert from Creighton

MDStewardship


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Monitor and reduce HAIsDetect outbreaks and resistanceManage/contain resistance and outbreaksPrevent via stewardship and reduced transmissionEducational resources for HCWsEducation for public website

Goals of DHHS HAI Team


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National Healthcare Safety Network‐CDC‐now reportable in NETied to reimbursement‐CMSReview SIRs, Validate Data, Brainstorm reduction strategiesAll PPS Hospitals, LTACHs, and Rehab

• CLABSI

• CAUTI

• SSI Colectomy and TAH

• CDI

• MRSA Bacteremia

• Dialysis Centers‐BSI, ABIC starts

Monitoring HAIs

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Nebraska HAI 2017


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Creation of a database containing susceptibility patterns for all reportable organisms

Slowly rising in NEEfforts to reduce

• Antibiotic stewardship

• Reducing transmission inter‐facility

• Contact precautions

• Environmental cleaning

Clostridium difficile

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Reportable since 2010Requires appropriate receipt of HL7 formatted messages from hospital to secure servers

End result is a line list• Screen for resistant organisms (CRE, VISA/VRSA, colisitin resistance)

• Detect clusters of MDROs

• Follow development of resistance over time

Antibiotic Susceptibility Data Registry


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All CREsCP‐CRECR‐PseudomonasColistin R‐Acinetobacter, mcrVISA, VRSACandida auris

Monitoring for Resistance


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Coordination with LHDDefining outbreaksDefining protocolsEducation to facilitiesLooking for colonization

Outbreak Detection and Management

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Non‐susceptible to any carbapenem• 4mcg imipenem. meripenem, doripenem

• 2mcg ertapenem

• OR + for carabapenemase

Send to NPHL for:• Carbapenemases

• Phenotypic testing

• Molecular testing

• If + phenotypic, ‐molecular ??? novel

Carbapenem Resistance


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Amp‐C or ESBL + loss of porinsCarbapenemases‐ moable genetic components (CP‐CRE)

• Klebsiella pneumoniae Carbapenemase (KPC)

• New Delhi Metallo‐B‐lactamase (NDM)

• Verona Integron‐encoded metallo‐B‐lactamase (VIM)

• Oxacilinases‐48‐type carbapenemase (OXA‐48)

• Imipenem metallo‐B‐lactamase (IMP)



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All CREs contact precautions • While awaiting confirmation of presence of a carbapenemase

• Private room and contact precautions

• Contact DHHS‐Dr. Pedati or Dr. Tierney

• Will work IP to determine colonization testing plan

• Will send swabs to facility to culture contacts to detect colonization

• Use transfer form


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LegionellaNon tuberculous mycobacteria(NTM)Non‐enteric gran negative rod bacteria (GNR)

• Pseudomonas

• Burholderia

• Aeromonas

Enteric bacteria• Cryptosporidia

• CRE

• E.coli

• Salmonella

Microorganisms that like water


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Aerosolization• Inhalation‐Legionella

• Falls on top surfaces or wounds‐NTM

Direct contact from water‐NTM, AeromonasContamination of environment–nonenteric GNR

• Use of common equipment

• Hands of HCWs

Mechanisms of Illness


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Moderate to severe “atypical” pneumonia (milder form: Pontiac fever) Acquired from inhalation of small droplets of water that contain Legionella bacteria. ≥50 years, current or former smokers, and those with chronic diseases or a weakened immune system are at higher risk for Legionnaires’ disease.

Symptoms‐Cough. Fever, SOB, HA, muscle aches, less commonly nausea, diarrhea Incubation‐2‐14 days Diagnosis‐urinary antigen, sputum or bronch PCR inc resp panel and/or culture Case Fatality Rate‐10% Treatment‐macrolides, fluoroquinolones, tetracyclines, tigecycline

Legionella

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2012 2013 2014 2015 2016

Num

ber

of C

ases

Year

Number of Legionella Cases by Year, Nebraska


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National Information21 jurisdictions around the country Active Surveillance for Legionella3,100 cases Overall mortality 10%20% of cases healthcare associated

• 3% definite (previous 10 d in HCF)

• 17% probable (part of previous 10d in HCF)

Mortality of definite HCA cases‐25%

Healthcare‐Associated Legionella

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Legionellosis outbreaks most often occur in hotels, long‐term care facilities, and hospitals.

Legionella bacteria grows best in building water systems that are not well maintained, especially where levels of chlorine or other disinfectants are low and water temperatures are optimal for growth.

The most common sources are potable water (e.g., drinkable water used for showering), cooling towers, hot tubs, and decorative fountains.

The key to preventing outbreaks is good management of building water systems, in accordance with industry recommendations.

Prevention is critical as Legionella was the cause of 66% of all potable water‐associated outbreaks reported to CDC during 2011–2012 (Beer et al., 2015).

Healthcare‐Associated Legionella


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Percentage of outbreaks and cases of Legionnaires’ disease, by environmental source — North America, 2000–2014

Garrison LE, Kunz JM, Cooley LA, et al. Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires’ Disease — North America, 2000–2014. MMWR Weekly Report 2016;65:576‐584.


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Garrison LE, Kunz JM, Cooley LA, et al. Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires’ Disease North America, 2000–2014.

MMWR Weekly Report 2016;65:576‐584.

• In 70% of outbreak cases inadequate water disinfectant levels were reported and in 52% of cases water temperature was found to be inadequate to prevent growth. Both were an issue in several cases.

• Indications of inadequate maintenance of hot tubs and decorative fountains were almost always noted.

• Among the investigations where outbreaks were believed to be associated with unmanaged external changes, nearby construction (43%) and problems with water mains (43%) were most frequently noted.

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Legionella minimization activities involve the implementation of engineering controls to limit the growth of Legionella, monitoring water quality, and assessing any potential risks.

Legionella growth in building potable water distribution systems is primarily suppressed by the implementation of engineering controls such as the maintenance of appropriate water temperatures and biocide levels.

Goal ‐ Minimizing the Presence of Legionella Bacteria


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There is no evidence‐based consensus or recommendation regarding routine water testing of Legionella bacteria for the prevention of disease.

If a program team decides to test for Legionella bacteria in their water systems, the ASHRAE standard does not make recommendations regarding the sampling method, the number of sites to test, how often to test, or what laboratory method should be utilized for analysis.

Water Testing for Legionella Bacteria


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100% prevention of exposure to Legionella is not possible, given host susceptibility, pathogen virulence, environmental prevalence, and water distribution system configurations and conditions, but prevention and control practices can be implemented to reduce the risk of exposure.

Legionella Growth

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References


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Provides a framework for proactively managing building water systems to reduce the potential for Legionella growth.

Provides guidance that does not have regulatory authority unless it is incorporated into local building or plumbing codes.

Applies to healthcare facilities where patients stay overnight, people with chronic or acute medical problems or weakened immune systems are housed or treated, and where people >65 years, with or without on‐site skilled nursing staff are housed.

2015 ASHRAE Standard 188American Society of Heating, Refrigerating, and Air Conditioning Engineers


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Defines:• Types of buildings and devices that need a water management program

• Components of a water management program

• Devices (e.g., hot tubs, cooling towers) that need to be controlled in order to prevent the growth and spread of Legionella

• Who should be on a water management program team

• When and how often water management programs should be reassessed and updated

Note: It does not provide guidance on target water parameters, such as temperature and disinfectant levels. It also does not describe how to perform emergency remediation or give guidance about what to do if cases of disease are associated with the facility.

2015 ASHRAE Standard 188

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Addresses the risk of inhalation or aspiration of Legionella bacteria while minimizing the risk of scald injury from exposure to hot water.

It is not possible to maintain water temperatures at the outlet that kill Legionella bacteria and simultaneously eliminate the possibility of scald injury without the installation/integration of anti‐scald devices into plumbing fixtures or water tempering valves.

VHA Directive Regarding Water Temperature


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Minimum concentrations of biocides can inhibit the growth of Legionella in building potable water distribution systems.

The use of one or more installed systemic water treatment system(s) may be necessary to supplement any residual disinfectant present in incoming water.

The efficacy of biocides on suppressing or killing waterborne pathogens is dependent on the presence of organic and inorganic contaminants, pH levels, water hardness, disinfectant concentrations, and contact time.

The minimum concentration of biocide necessary to suppress bacterial growth may vary from building to building and even within buildings.

VHA Directive Regarding Biocides


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1. Maintain a current schematic of the water distribution system (i.e., distribution, circulation, storage,

heating, cooling, treatment, and monitoring points). Identify any areas in which water is processed

differently (e.g., hemodialysis and sterile processing).

2. Complete an annual risk assessment of the building for temperature, biocide, and receptor risk factors.

Examples: Changes to the distribution system? A new dialysis center?

3. Establish engineering control strategies to inhibit Legionella growth and to identify control mechanisms

for preventing scald injury

4. Identify water system management points where monitoring and controls can be implemented to

prevent the growth of Legionella and prevent scald injury.

5. Establish a schedule of routine monitoring of the engineering control strategies and document when each

water quality and control measure was monitored and what and when corrective action was taken.

6. Validate control measures to ensure they are effectively inhibiting Legionella

growth.

Components of a Healthcare‐associated Legionella Disease(HCA‐LD) Prevention Plan

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#1 – Schematic

#4 – Identify water system management points


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Potable water entering each building should be continuously monitored for incoming water pressure, temperature, pH, dissolved solids, and oxidant residual.

If a building uses domestic hot water storage tanks, water temperature of all such storage tanks must be maintained at a minimum of 140 degrees °F (60 degrees Celsius (°C) to kill legionella bacteria.

The minimum discharge temperature for instantaneous and semi‐instantaneous heat exchangers must be 130°F (54.4°C).

Water in the potable hot water distribution system piping must be no lower than 124°F(51.1°C) (prior to any temperature‐reducing mixing valve or anti‐scald device at the water outlet).

Cold water temperature throughout the system should be maintained at or below 67°F (19.4°C) to the greatest extent practicable to inhibit growth.

#3 Engineering Control Strategies for Prevention of LegionellaGrowth ‐ Temperature


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Continuous temperature monitoring must be conducted, at a minimum, in the following areas:

• Incoming water supply to the building

• Water storage tanks

• Hot water discharge at the hot water source equipment

• Hot water return proximal to the hot water source equipment

• Water at the return of circulation loops

• Water supplied to representative outlets (e.g., loop or branch, hydraulic remoteness, flow).

The use of mixing valves and anti‐scald devices on all outlets where people access water from the potable hot water distribution system is required in order to prevent scald injury. The water temperature delivered from the outlet must not exceed 110°F (43.3°C).

#3 Engineering Control Strategies for Prevention of LegionellaGrowth ‐ Temperature

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Disinfectant and other chemical levels in cooling towers and hot tubs should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (i.e., slime) should be cleaned.

Monitor biocide residual levels at distal water outlets in the hot and cold potable water distribution systems to determine if levels are within the established control limits and in compliance with regulatory requirements.

Flush hot and cold water at outlets (e.g., sink taps, showers) at least twice per week, particularly those not in routine use or which experience low water flow, to prevent water stagnation for extended periods of time.

Decorative fountains should be kept free of debris and visible biofilm.

#3 Engineering Control Strategies for Prevention of LegionellaGrowth ‐ Disinfection


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Continually monitor the oxidant residual levels in the building incoming water supply and at representative outlets (e.g., loop or branch, hydraulic remoteness, flow) to determine if any disinfectant water treatment from the municipality or other source is present when the water reaches the building and after distribution in the building.

Minimum concentrations of oxidant residual necessary for inhibition of Legionella growth may vary from building to building. The following minimum detected oxidant residual levels at hot and cold water outlets are suggested as guidance.

• 0.5 milligrams (mg) per liter (L) for chlorine (as free chlorine)

• 0.5 mg/L for monochloramine

• 0.3 mg/L for chlorine dioxide



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Facilities may choose to implement a systemic supplementary water treatment system(s) in buildings to supplement municipal or source treatment of water. Factors to consider include but are not limited to: • The levels of oxidant residual in the incoming water supply and/or at outlets

• Past history of HCA‐LD

• Results from environmental and clinical validation testing


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If the facility decides to install a supplemental water treatment system in a building, then the following actions are required: • With the installation of treatment for the purpose of eliminating Legionella or any other contaminant, DHHS would require plans and specifications submitted for approval by a Nebraska registered engineer.

• The facility would then need to apply for a permit to operate a Public Water System (PWS). Such a PWS would be considered to be a consecutive system (even though the facility would be receiving water from a PWS, they are adding treatment to the water.)

• U.S. EPA approved oxidants for disinfection include: chlorine, monochloramine, and chlorine dioxide. The manufacturer of the system must provide the minimum and maximum outlet biocide levels in writing for both hot and cold water.



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Anticipate hazardous conditions that could be associated with scheduled or unanticipated changes in water quality, such as: • System start up

• System shut down

• Regularly scheduled maintenance

• Renovations, construction, and installation of new equipment on your property

• Equipment failure

• Water main break or other service interruptions

Control Measures


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It is important to consider the implications of Legionella mitigation strategies on special use water systems within the building. For example, chemical disinfectants may result in the introduction of products into, or the formation of disinfection.

The impact of mitigation strategies must account for potential toxicity, methods for removal of the chemical agent and byproducts from the special use water system, and availability of assay methods to measure the chemical agent and byproducts for assuring patient safety.

Employees responsible for the oversight of special use water systems are to be consulted during the development and implementation of water treatment strategies for Legionella and promptly notified of any changes in treatment procedure.

Special Use Water Systems Hemodialysis, Laboratory, Pharmacy Compounding

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Water temperature and biocide residual testing, as well as corrective actions, must be documented to determine if the engineering controls are effectively controlling Legionella growth in the building’s potable water distribution systems.

(#6) Validation includes both a clinical component to assess incidence of HCA‐LD and an environmental component to assess the need for corrective actions.

#5 Documentation of Routine Monitoring + Annual Review = Risk Assessment (#2)


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If routine monitoring determines that the water temperatures or biocide residual levels from an installed system are not within the established limits, then the following actions, at a minimum, must occur: • Assess the reason(s) why the control(s) were not within the established limit.

• Take action promptly to satisfy implementation of the control measures to within established limits.

Point‐of‐use filters may be installed at specific outlets to prevent Legionella exposure to patients. This method may be of particular use in areas that treat high‐risk patients.

#6 Corrective Action Measures


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CORRECTIVE ACTION EXAMPLE

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CORRECTIVE ACTION EXAMPLE


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CONTINGENCY RESPONSE EXAMPLE


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CONTINGENCY RESPONSE EXAMPLE

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The Centers for Disease Control (CDC) has developed a toolkit that provides practical guidance on how to implement ASHRAE 188.

The CDC encourages all healthcare facilities to include clinical disease surveillance in addition to environmental surveillance in their Legionellosis risk management plan.

Toolkit (https://www.cdc.gov/legionella/maintenance/wmp‐toolkit.html)

CDC Toolkit


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CDC Environmental

Assessment Form

https://www.cdc.gov/legionella/downloads/legionella-environmental-assessment.pdf 15 pages

Note: Sampling should only be performed after a thorough environmental assessment has been done and a sampling plan has been made.


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CDC Sampling Procedure

https://www.cdc.gov/legionella/downloads/cdc-sampling-procedure.pdf 6 Pages

Note: This protocol is for collecting environmental samples for Legionella culture during a cluster or outbreak investigation or when cases of disease may be associated with a facility.

Sampling should only be done by a trained environmental professional.

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Environmental Legionella Isolation Techniques Evaluation Program (ELITE)• https://wwwn.cdc.gov/elite/Public/MemberList.aspx

• Provides a list of laboratories that can provide analysis for Legionella

• There are no laboratories on the list from Nebraska

CDC ELITE


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Triggered by…• A definite HCA‐LD case, a cluster or outbreak, or when cases of disease are suspected to be associated with a facility.

• Note: Prior to the implementation of emergency mitigation, stakeholders at the facility must be informed in order to facilitate safe implementation of the emergency procedures.

Emergency Remediation Potable Water Distribution Systems


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Includes one or both of the following procedures: • Shock chlorination. Increasing the chlorine level of the hot and cold water distribution systems to at least 2 mg/L and maintaining that level throughout the systems for at least 2 hours (but not exceeding 24 hours) and flushing all outlets. Chlorination of the hot water tank(s) or the water heater(s) to a concentration of 20 to 50 mg/L may be required to achieve this level of free chlorine residual.

• After shock chlorination the system must be thoroughly flushed before reuse. If post‐shock chlorination water testing indicates that Legionella bacteria are still present in the distribution system, it may be necessary to repeat with a higher concentration of chlorine (e.g., at least 10 mg/ml free chlorine residual throughout the system and at outlets for 24 hours or 200 mg/L for three hours).


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Include one or both of the following procedures: • Thermal Eradication. Temporary resetting of the temperature in the hot water distribution system(s) to 160 °F ‐ 170°F (71°C ‐ 77°C) while continuously flushing each outlet in the system for at least 30 minutes. Consideration needs to be given as to the feasibility of implementing thermal eradication depending on the design of the mixing valves in place.

• Legionella will likely reappear if proper routine water temperatures or residual biocide levels (or other supplementary systems or processes) are not maintained. Communication must occur to inform stakeholders once complete.



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Estimates of the annual prevalence and total cost of hospitalizations for Legionnaires’ Disease

in the USA (2006-2007)

Legionnaires’ disease

Mean total cost/hospitalization

— $26,741 $38,363 — $33,366

Proportion of hospitalizations withtype of insurance

8% 43% 39% 6% —

Number of hospitalizations/year

1040 5590 5070 795 13,000

Total hospitalization cost — $149,482,190 $194,500,410 — $433,752,020

Medicaid Medicare Commercial Uninsured TotalData sources : 2006–2007 Nationwide Inpatient Sample; Marketscan 2004–2005 Multistate Medicaid and 2006–2007 Medicare Supplemental and Commercial Claims databases. All costs in 2007 US dollars.


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Questions?

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Vision:

Grow Nebraska

Mission:

Create opportunity through more effective, more efficient, and customer focused state government

Priorities:• Efficiency and Effectiveness

• Customer Service

• Growth

• Public Safety

• Reduced Regulatory Burden

We Value:• The Taxpayer

• Our Team

• Simplicity

• Transparency

• Accountability

• Integrity

• Respect

Governor Pete Ricketts


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DHHS Accomplishments• Completed 19 of 25 initiatives in last years’ Business Plan and made substantial

progress on the others. Over 93% of the 213 deliverables were completed.

• Implemented Heritage Health, Medicaid’s managed care program integrating physical, behavioral and pharmacy health services.

• Launched the Behavioral Health System of Care for children and youth, integrating services and supports for those with a serious emotional disturbance through collaboration with public and private partners. Youth Mobile Crisis Response was the first service available statewide.

• Improved Economic Assistance ACCESSNebraska average call wait times from nearly 24 minutes in August 2014 to under the goal of five minutes.

• Since April 2016, ACCESSNebraska has exceeded the federal standard to process 95% of SNAP applications on time, consistently processing 98%-99% on time.

• Expanded Medicaid services for at-risk youth, gaining federal approval for multi-systemic therapy and functional family therapy.

• Established a Family Focused Case Management pilot in North Platte and Omaha, coordinating economic assistance and child welfare services to identify barriers and help clients reach self-sufficiency.

• Developed, gained federal approval for, and implemented Medicaid Developmental Disabilities Home and Community-Based Services waivers focused on person-centered, customer-focused planning.

• Reviewed all individuals on the Developmental Disability Registry of Unmet Needs to better determine service needs, funding source, and utilization data.

• Expanded the use of Alternative Response, which addresses the needs of families with less severe reports of child abuse and/or neglect so they avoid further involvement in the child welfare system, to 57 Nebraska counties.

• Developed a Medicaid Long Term Services and Supports redesign plan outlining opportunities for improvement and integration of services.

• Expanded access to, and enhanced use of, the Prescription Drug Overdose Prevention and Prescription Drug Monitoring program by providers.

• Created a more user friendly application process for Developmental Disability services, reducing the number of pages from 14 to 3, and slashing the wait time to determine eligibility from 69 days to 14.

• Developed a Centralized Data System across behavioral health system partners, allowing for improved data analysis and service planning for children and adults.

• Achieved national accreditation for the Division of Public Health, meeting national standards and increasing accountability and continuous improvement.

• Simplified licensing applications, streamlined screening, and shortened turnaround times for nurse, medication aide, and other licensees. The medication aide process decreased from 39 to nine days.


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DHHS 2017-2018 Priorities• Increase availability of community-based services through the Behavioral Health

System of Care for children and youth, reducing reliance on inpatient and residential services.

• Keep families together by stabilizing and strengthening families, helping prevent intergenerational poverty and achieving self-sufficiency.

• Establish the Beatrice State Developmental Center as a statewide resource providing short term intervention and respite services for individuals with developmental disabilities.

• Develop a standardized assessment and transition plan as part of the Medicaid managed care Long-Term Services and Supports Redesign initiative.

• Decrease the amount of time that elapses between when an individual accepts a funding offer for developmental disability services and when services begin.

• Increase the participation of pharmacies and enrollment of eligible users in the Prescription Drug Monitoring Program, and develop and implement naloxone education resources.

• Safely prevent and reduce the percent of state wards in out-of-home placements by implementing best-practice interventions and services.

• Implement Alternative Response statewide, resulting in families engaged with Alternative Response more likely to have their children remain in their home six months after case closure than families in Traditional Response.

• Develop and implement a web-based portal for caseworkers to use when completing a caregiver survey with foster parents in their home, saving 15 minutes per survey.

• Launch an electronic benefits transfer pilot for the WIC program, known as eWIC, that will offer flexibility and individualized nutrition education to families as well as providing additional data for program management.

• Reduce single state audit findings and questioned costs.

• Develop a web portal and implement changes to the child and adult abuse central registry to improve timeliness and accuracy of background checks.

• Improve the integration of community-based behavioral health treatment and fiscal data through the Centralized Data System and Electronic Billing System.

• Develop the data management analytics system and claims broker services as part of the Medicaid Management Information System replacement project.

• Implement NTRAC, a new Medicaid eligibility and enrollment system to ensure compliance with federal requirements.

• Decrease the average days waiting for admission to the Lincoln Regional Center for both court-ordered individuals and mental health board-committed individuals.

• Develop and implement a quality management system for developmental disability home and community-based services and intermediate care facility services.

• Streamline operations to reduce new hire turnover and the average length of time from job posting to job offer, and to consolidate document imaging and interactive voice technologies.

• Decrease time for issuing provisional center-based child care program licenses and initial certification for community-based developmental disability provider agencies.

• Review child care and preschool regulations to determine modifications to reduce regulatory burden and make them clearer.

Prevention of Healthcare‐ Associated Legionella …€enteric gran negative rod bacteria (GNR) ......

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